MOER 2015 DENTAL CARIES JADA 2015 PIIS0002817714000294

8/18/2019 MOER 2015 DENTAL CARIES JADA 2015 PIIS0002817714000294

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ORIGINAL CONTRIBUTIONS

JADA 146(2) http://jada.ada.o ! "#$ %a &

ARTICLE 1

CO+,R STOR-● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

The American Dental Association Caries Classi cation System for Clinical PracticeA #po t o th# A # 0 a D# ta3 A o 0at0oCo% 03 o S 0# t0 A5a0

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ORIGINAL CONTRIBUTIONS

2 JADA 146(2) http://jada.ada.o !

ABSTRACT

Ba ?! o% d. The caries lesion, the mostcommonly observed sign of dental cariesdisease, is the cumulative result of animbalance in the dynamic deminerali ation and reminerali ation process that causes a netmineral loss over time. & classi cation systemto categori e the location, site of origin,extent, and !hen possible, activity level ofcaries lesions consistently over time is

necessary to determine !hich clinicaltreatments and therapeutic interventions areappropriate to control and treat theselesions.7#thod . 'n ())*, the &merican Dental&ssociation +&D& convened a group of expertsto develop an easy-to- implement cariesclassi cation system. The &D& $ouncil onScienti c &ffairs subse"uently compiledinformation from these discussions to createthe &D& $aries $lassi - cation System +$$Spresented in this article.

Co 3% 0o . The &D& $$S offers cliniciansthe capa- bility to capture the spectrum ofcaries disease pre- sentations ranging fromclinically unaffected +sound tooth structure to noncavitated initial lesions toextensively cavitated advanced lesions. The&D& $$S supports a broad range of clinicalmanagement options necessary to treat bothnoncavitated and cavitated caries lesions.= a t0 a3 I p30 at0o . The &D& $$S isavailable for implementation in clinicalpractice to evaluate its usability,

reliability, and validity. eedback fromclinical practitioners and researchers!ill allo! system improvement. Use of the&D& $$S !ill offer standardi ed data thatcan be used to improve the scienti crationale for the treatment of all stages ofcaries disease.@#& o d4. $aries classi cation systemcaries lesion classi cation caries locationcaries extent caries activity cariesmanagement.

&D& ()/01/23+( 145-*3http://dx.doi.org/ 10 .1016 /j.adaj. 2014 .11 .018

http://jada.ada.org/http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://dx.doi.org/10.1016/j.adaj.2014.11.018http://jada.ada.org/http://dx.doi.org/10.1016/j.adaj.2014.11.018


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primarily uses the 6.7. 8lack system forcaries classi- cation, referring to theintended surgical +operative outcome inclassifying the caries lesion. Dr. 8lack ssystem does not address noncavitatedlesions, yet,as 8lack anticipated in 1896 , The dayis surely coming . !hen !e !ill beengaged in practicing preve nt ive ratherthan reparative dentistry. 10 The&merican Dental &ssociation +&D& $aries$lassi cation System +$$S is designedto help address that goal.

8ecause the caries lesion has differentforms of clinical presentation during thedisease process, clini- cians need aclassi cation system that supports appro-priate treatment decisions using ava ila blenonsurgical and surgical approaches. 11 - 13$lassifying lesion location,site of origin, extent, and if possible,activity, should be part of all dentalevaluations to facilitate ris k ass essmentand treatment recommendations. 4 , 11 , 12

9pidemiologic studies measuring theprevalence and severity of dental carieshave used modi ed versions of :lein andcolleagues decayed, missing, and lled +D; 14 or 6ruebbel s decay ed , extractionindicated, and lled +def 15 indexesho!ever, these indexes only capturecavitated lesions.


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!hether or not the tooth surface is fullycavitated.to a speci c treatment approach. 'n addition, the &D& $$S F contrasted !ith some cariesclassi cation systems F links clinicallesion presentation to radiographic ndings and provides an approach toidentify, !hen possible, caries lesionactivity over time.

ABBREVIATION KE ! ADA: &merican Dental&ssociation. CCS: $aries $lassi cation System.CRA: $aries risk assessment. DMF: Decayed,missing, and lled. ICDAS: 'nterna- tional$aries Detection and &ssessment System.


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INCR,ASING 7IN,RAL LOSS Ca90tat0o o th# S% a #

So% d 4% a # I 0t0a3 0 # a3 3o44 7od# at# 0 # a3 3o44 Ad9a #d 0 # a3 3o44


"i#$re! Ca 0# 3# 0o #p # # t a o t0 %% o #t 0 # a3 3o .

D,SCRI=TION O" T


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the tooth is classi ed as advanced. 'nepidemiologic studies, these lesions areclassi ed as decayed.

=ote that any caries lesion describedabove also may be associated !ith anexisting restoration or sealant.

$orrelating the appearance of pit-and- ssure caries lesions relative tosuspected histologic dentin penetra- tionmay be useful in clinical decision-making. orpit-and- ssure caries lesions, the '$D&S$oordinating $ommittee published datacorrelating the clinical appearance ofthese lesions !ith the histologic examination of the teeth af ter extraction. ?erthe published data, 16 , 17 0 % to 50 % of &D&$$S initial pit-and- ssurecaries lesions could exhibit histologicdentin penetration like!ise, 50 % to 88 %of &D& $$S moderate pit- and- ssure carieslesions may penetrate histologically todentin. &D& $$S advanced pit-and- ssurecaries lesions, because they are fullycavitated, !ould be expected to h av e 100 %

histologic penetration to dentin.15

$onsideration of these probability rangesfor dentin deminerali ation could bebene cial in any caries management systemthat includes treatment considerations.

Bastly, the topic of l ongitudinalassessment of activity 28 deservesdiscussion. The &D& $$S scores visible changes in tooth structures and,therefore, cannot score initial cariesactivity before visible structural changesoccur. Chere there are visible signs ofcaries lesions, it is often possible todetermine !hether the lesion is active orarrested. Table 3 lists factors toconsider ! hen making a clinicaldetermination of lesion activity or inactivity. The lesion is @udged as active!hen there are manifestations suggestiveof continued deminerali a- tion. Thisprocess can be follo!ed over time tofurther determine the presence of diseaseactivity, !hich may in uence the decisionregarding nonsurgical or surgical intervention. Detection of arrestedlesions indicates the disease process isno longer active. &ffected dentin is a term used to describe dentin that hasbeen exposed to bacterial acids but isnot yet infected by cariogenic bacteria.Depending on clinical assessment of carieslesion activity at the time ofexamination, affected dentin may be softif deminerali ation is occurring +activeor may be hard if the lesion is arrestedAreminerali ed +inactive . &ffected dentinoften is stained or discolored, !hich isnot necessarily a reason for surgicalremoval partic ul arly if the dentin hasreminerali ed. 29

$aries lesion activity assessment,despite the limitations of this metric,may be a key factor for monitoring noncavitated lesion progression orregression over time, and lesion activityalso may be a useful metric for gaugingchemotherapeutic treatment effectiveness.Besion activity should be considered !henperforming a direct clinical examinationand !hen evaluating radiographs.9vidence of lesion activity over time,based on changes +or lack thereof in theradiolucency

TABL, K

Cha a t# 04t0 4 o a t09# a d0 a t09# a 0#4 3#40o 4.HACTI+IT- ASS,SS7,NT "ACTOR

CARI,S L,SION ACTI+IT-ASS,SS7,NT

L0?#3& to B# I a t09#/A #4t#d

L0?#3& to B# A t09#

Lo at0o o th# L#40o

L# 0o 0 ot 0 a p3a %# ta! at0oa #a

L# 0o 0 0 a p3a %#ta! at0o a #a

(p0t/ % #app o 0 a3 !0 !09a3)

=3a %# O9# th# L#40o

Not th0 ? o t0 ?& Th0 ? a d/o t0 ?&

S% a # App#a a21#

Sh0 &8 o3o :$ o E $3a ?

7att#/opa %#/3o o 3% t# 8 o3o : h0t#E

Ta t03# "##30 ! S ooth ha d# a #3/ ha d

Ro%!h # a #3/ o td# t0

G0 !09a3 Stat%4(I th# L#40o I4Lo at#d N#a th# G0 !09a)

No 0 a at0oo $3##d0 ! o

p o$0 !

I a at0o$3##d0 ! o p o$0 !

H So% #: ,? t a d a d o33#a!%# . 2

+progression or arrest could have adirect impact on clinical treatmentdecisions. &n arrested, reminerali ed, noncavitated lesion +!hite or bro!n isacid resistant and no longer an indicatorof active caries disease.This factor should be considered !henassigning caries risk status. & cavitatedlesion by nature is more likely to beactive and progress because self-cleaningis dif cult.

USING T


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reminerali e the previously intactsurface 32 ho!ever,a rounded +blunt or dull explorer or aball probe can be used to evaluatesurface texture +rough versus smooth bydragging the instrument over the surface in "uestion.

The visual and tactile examination ofthe teeth is enhanced !hen the clinician

cleans and dries the pits and ssures!hile recording ndings tooth-by-toothto determine if each pit or ssure issound, or, if a caries lesion ispresent, noting the lesion extent+initial , moderate, or advanced as

Table 2 E and, !hen possible, recordingactivit y for each lesion as sho!n inTable 3 . & comparison to the patient sprevious examination ndings !ill helpassess caries lesion activity. =otethat for surfaces +not teeth !here morethan one distinct, independent lesion ispresent, each lesion is classi ed.

=ext, the smooth surfaces are examinedby drying the facial aspect andproceeding around the dentition +as apractitioner !ould !hen performingperiodontal probing , eventuallytransitioning to the lingual surfaces,again recording tooth-b y-tooth the statusof each lesion + Table 2 , and, !henpossible, recording activity +Table 3!ith particular attention to changes overtime.

Bastly, the approximal surfaces areexamined using the visual and tactilemethod !here possible. Chen direct accessis limited because of ad@acent tooth con- tact, radiographs or elastomeric toothseparation can be used for examina tion tor ecord the status of each lesion +Table

2 . Chen se"uential radiographs spanningthe appropriate amount of time asindicated for each patient are av ailable for an approximal caries lesion, Table 2

may be used to determine the radiographicprogression or regression and, therefore,the activity of that caries lesion overtime. =ote that additional evidenced-based ad@unctive aids to detect carieslesions, such as uorescence-basedtechni"ues or other light- based cariesdiagnostic tools, may emerge and, as theyare developed, clinically tested andvalidated, they may contribute to a moreprecise placement of caries lesions in the&D& $$S categories.

'f a caries lesion involves t!o +ormore tooth surfaces and the t!o +ormore surfaces are obviously con@oinedclinically, the surfaces are recordedtogether as a single unit. #o!ever, onlythe most likely site of origin !ould berecorded for that lesion. or example, a single lesion consisting of the mesio-occlusal surfaces together, thus creatinga single advanced caries lesion @udged tobe active and to have started on theapprox- imal surface, !ould be recorded inthe follo!ing manner1 no. 12 mesio-occlusal surfaces, approximal origin,advanced extent, active.

9ach site of visible change can bescored as inactive +' or active +& .=ote that activity cannot be determinedby radiographic appearance except insitu- ations in !hich it is possible tocompare se"uential

radiographic images of the same carieslesion exposed over an appropriate spanof time. 'f the practitioner is unable todetermine the activity level for a ca riesl e sion usi ng the activity factors in Table3 +Table 2 for se"uential radiographs , thelesion activity is recorded as

undetermined +UD . 'f the practitionerdecides not to assess activity level for alesion, !here s uch an a ssessme nt ispossible using Table 3 +Table 2 for radiographs , it is recorded as notrecorded +=> . Details of the mosteffective method for recording caries activity !ill be better developed duringactual &D& $$S testing.

The follo!ing are additional examples ofcaries lesion classi cation recordingusing the &D& $$S as detailed in Tables 1 -3 1

E no. 19 facial surface, pit and ssureorigin, initial extent, inactive

E no. 3 occlusal surface, pit and ssure origin,advanced

extent, activeE no. 3 facial surface, cervicalAsmooth

surface origin, moderate extent,inactive

E no. 7 facial surface, root origin,moderate extent, active

E no. 20 distal surface, approximal origin,moderate extent, active + 2 bite!ingradiographs taken 1 year apartsupport the clinical @udgment of activebased on progression of caries lesiondisplayed on the bite!ings and consistent!ith th e moderate extent based on the Table 2 fact ors for this caries lesion .

>efer to Table 1 , to the examples sho!nin Table 2 , and to the criteria displayedin Table 3 to vie! additional speci cdetails and examples that illustrate ho! the &D& $$S may be applied in clinicalpractice.

The approximal site is fre"uently notaccessible for direct examination due tocontact !ith the ad@acent tooththerefore, other factors for makingclinical treatment decisions may beuseful. 'n 1992 , ?itts and >immer 25 correlated radiographic radiolucency depthto cavitation. 'n their study, none of thesamples !ith a radiolucency in the outerone-half of the enamel !ere cavitated. 'fthe radiolucency appeared in the inner one-half of the enamel on the radiograph, thepercentage of cavitation !as approximately10 . 8 % in permanent teeth, and 2 . 9 % inprimary teeth. These percentages increased to 40 . 9 % in permanent teeth and 28 . 4 % inprimary teeth if the radiolucency extendedto the outer one-half of dentin, and to100 % cavitation in permanent teethand 48 % in primary teeth if theradiolucency extended to the inner one-half of the dentin.

The &D& $$S, as sho!n in Table 2 , uses anomenc la ture that divides the dentin intothirds 32 instead of halves. Thisnomenclature +9 0 , 9 1 , 9 2 , D 1 , D 2 , and D 3 33is simply a !ay to express the depth of a radiolucency as measured on a dental

radiograph.


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Dividing the dentin into thirds, ratherthan halves, results in ner gradationto allo! for speci c attention


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to the D 1 a re a !here, according to ?ittsand >immer, 25 cavitation is less likely.>adiographic extent is only an estimateon the continuum of mineral lossdescribed previously and may not al!ays tneatly into one lesion stage. or example,because the middle of the D 2 stage is exactly half!ay from the dentinoenamel@unction to the pulp, there may be someearly D 2 radiolucencies that may not beclinically cavitated, !hereas deeper D 2 radiolucencies are more likely to becavitated. The use of tooth separation,!here possible, may be helpfulin con rming cavitation of a deep D 1 orshallo! D 2 radiolucency. Thesecorrelations may be useful !hen makingtreatment decisions.

't is anticipated that entry of the &D&$$S examination data may be most easilyand effectively accom- plished usingelectronic dental records con gured !ith appropriate user-friendly data entry!ork o! that offers drop-do!n pick listsor other straightfor!ard data selectionmethods. 'n addition, electronic dental record entry !ill allo! automated use ofstandardi ed computable diagnostic codingterminologies to describe thepractitioner s clinical ndings for eachcaries lesion. urthermore, electronicentry of the caries lesion data elements!ill support calculations that, over atime span, !ill enable practitioners totrend progression or regression of carieslesions. This is analogous to the electronic entry of periodontal probingdata in milli- meters at 6 points aroundeach tooth to allo! calcula- tion of theclinical attachment level for each probedsite. Such calculations, based on clinicaldata collected at 2 different times !ithan appropriate interim bet!een theseclinical observations, improve trendingthe data to track the progression orregression of periodontal or carieslesions over time. 'n the absence of anelectronic dental record, the practitionercan easily implement the &D& $$S using apaper form and manual calculations regarding caries lesion progression overtime.

=OT,NTIAL B,N,"ITSTo determine the effectiveness of cariesmanagement strategies aimed at improvingpatient care, a $$S must be reliable,valid, and easily integrated into clinicalpractice +that is, usable . >esearch hasreported a lack of reliability indetecting early lesions amongclassi cation systems used in practice. 34 'n addition, the availability of

classi

cation factors needed in dailyclinical practice are limited in all ofthese systems. The &D& $$S F !ith an integrated process for capturing usefulcomponents of the caries process F is no!available for the next step1 initiation ofreliability and usability testing bypracti- tioners in clinical and researchsettings. The feedback from practitionersand researchers !ill lead to im- provements in the system. The results ofprior studies examining the reliability ofcaries classi cation in 2011 and 2013 canoffer insight into acceptable limits fo ragreement in evaluation of the &D& $$S. 34 -35

SU77AR-Bimiting the dental examination tocavitated lesions by using the 6.7. 8lacksystem fails to recogni e the earliest signs of caries lesions and underestimatesthe prevalence and severity of disease.

urthermore, this approach only describescavitated lesions, thus limiting thecapacity to assess the effectiveness of

preventive interventions for the earlystages of caries disease. The &D& $$S attempts to correct these limitations byincluding reliable criteria fordetecting early lesions and for monitoring the clinical status of these earlylesions over time. 't is hoped that the&D& $$S !ill facilitate measuring theeffectiveness of contemporary cariesdisease management strategies inclinical practice as the profession continues to strive to!ard improvingoverall patient health through improvedoral health. n

Dr. Foung is a professor, Department of Dental ?ractice,University of the ?aci c, San rancisco, San rancisco,$&.

Dr. =ovG is the director of practice improvement,DentaHuest 'nstitute, Cestborough, ;&, and an ad@unctassociate professor, Department of >estorative Dentistry,Boma Binda University, Boma Binda, $&.

Dr. Ieller is the associate dean for clinical affairs,and a professor, oral health practice, $ollege ofDentistry, University of :entucky, Bexington, :F.

Dr. #ale is a colonel, Dental $orps, a commander, US&rmy Dental and Trauma >esearch Detachment, and thedirector, craniomaxillofacial research, US &rmy 'nstituteof Surgical >esearch, San &ntonio, TJ.

Dr. #art is the vice chair, $ouncil on Scienti c&ffairs, &merican Dental &ssociation, the director,$raniofacial ?opulation Sciences >esearch, and aprofessor, Department of ?eriodontics, $ollege ofDentistry, University of 'llinois at $hicago, $hicago,'B.

Dr. Truelove is the chair, $ouncil on Scienti c &ffairs,&merican Dental &ssociation, and a professor, Departmentof


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4. Telle ;, 6ome , ?retty ', 9ll!ood >, 'smail &. 9vidence on existing

caries risk assessment systems1 are they predictive of future cariesN Com" munity Dent ral !pidemiol .

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MOER 2015 DENTAL CARIES JADA 2015 PIIS0002817714000294